Implantable Cardioverter-Defibrillator Therapy for Primary Prevention of Sudden Death After Alcohol Septal Ablation of Hypertrophic Cardiomyopathy

Cuoco, Frank; Spencer, William H.; Fernandes, Valerian; Nielsen, Christopher D.; Nagueh, Sherif F.; Sturdivant, J. Lacy; Leman, Robert B.; Wharton, J. Marcus; Gold, Michael R.

doi:10.1016/j.jacc.2008.07.061

Cited by 78 publications

(63 citation statements)

References 42 publications

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“…In the last decade, a large body of literature (including a number of meta-analyses) has reported the results of this procedure (13,(22)(23)(24)(25)(26). Alcohol septal ablation can often relieve obstruction and improve symptoms (at least during an intermediate period of follow-up) when performed in properly selected patients by interventional cardiovascular specialists with extensive experience with this procedure (13,22,24,25). However, a note of caution should be raised regarding limitations of the literature on alcohol ablation.…”

Section: Alcohol Septal Ablationmentioning

confidence: 99%

“…These small arteries form an intricate network of anastomoses that may either limit the area of myocardial ischemia to segments of the septum that do not contribute to outflow obstruction or extend ischemia to other areas of the left ventricle with the potential for widespread myocardial damage (31)(32)(33). This difficulty in predicting the myocardial distribution of alcohol is also the basis for the 10% to 15% rate of complete heart block and permanent pacemaker implantation, as the conduction system is located in the posterior ventricular septum and consequently exposed to damage by the injected ethanol (1,8,12,22,25,30). The risk of such complications is directly related to operator and institutional experience with the alcohol septal ablation procedure.…”

Section: Technical Issuesmentioning

confidence: 99%

“…Nevertheless, in a recent multicenter European study, appropriate ICD shocks for ventricular tachycardia or fibrillation were 8-fold more common after septal ablation than surgical myectomy (13). Furthermore, major HCM centers have reported a higher rate of ventricular tachyarrhythmias, cardiac arrest, or appropriate ICD interventions after alcohol septal ablation (12,38), and some centers have prophylactically implanted ICDs for primary prevention after septal ablation (22). In contrast to these recurring concerns regarding arrhythmic risk associated with alcohol septal ablation, available data show that surgical myectomy extends survival with an exceedingly low rate of events, including ventricular tachyarrhythmias and sudden death, during long-term follow-up (5,7,10).…”

Section: Arrhythmogenic Potential Of Alcohol Septal Ablationmentioning

confidence: 99%

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Alcohol septal ablation: in which patients and why?

Spirito¹,

Rossi²,

Maron³

2017

Ann. Cardiothorac. Surg.

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At present, surgical septal myectomy is regarded as the "gold standard" treatment for most patients with obstructive hypertrophic cardiomyopathy (HCM) and drug-refractory symptoms. However, the best results are obtained by those surgeons who have extensive experience with this operation at a small number of referral centers. In the mid-1990s, percutaneous alcohol septal ablation was introduced as an alternative to myectomy to reduce LV outflow gradient and heart failure symptoms in patients with obstructive HCM. However, certain features of alcohol ablation limit its applicability to carefully selected patients.Because this procedure involves the injection of 1-4 mL of 96% ethanol into a septal perforator of the left anterior coronary artery to produce a myocardial infarction (with septal thinning, outflow tract widening and gradient reduction), alcohol ablation is limited by the size and distribution of the septal perforator branches. In addition, rich blood supply from other septal branches not occluded by the balloon and from the posterior descending coronary artery may restrict myocardial ischemia to portions of the septum that do not contribute to outflow obstruction. Septal hypertrophy may be either mild or particularly marked, and abnormalities of mitral valve apparatus may also play a major role in outflow obstruction. When such features are present, alcohol-induced septal thinning is unlikely to significantly reduce the gradient. In addition, persisting uncertainties regarding the risk for ventricular tachyarrhythmias after alcohol ablation suggest this procedure should be limited to patients of advanced age, patients at unacceptable operative risk due to comorbidities, or those with strong aversion to surgery. Further progress in the treatment for patients with obstructive HCM and severe refractory symptoms will come from assuring proper patient selection for alcohol septal ablation, as well as increasing the number of surgeons and centers experienced in performing septal myectomy. PerspectiveIn patients with hypertrophic cardiomyopathy (HCM), left ventricular (LV) outflow obstruction with a pressure gradient between the LV outflow tract and aorta is caused by systolic anterior motion of the mitral valve against the septum (1), and is identified at rest or with physiologic exercise in about 70% of patients evaluated at tertiary referral centers (2). Obstruction to LV outflow obstruction is associated with mitral valve regurgitation, disabling heart failure symptoms and increased cardiovascular mortality (3,4). For almost 50 years, transaortic septal myectomy has represented the standard surgical approach for the treatment of patients with obstructive HCM and severe symptoms refractory to medical treatment (1,5-7).In the mid-1990s, percutaneous alcohol septal ablation was introduced as an alternative to surgical myectomy to reduce the LV outflow gradient and heart failure symptoms in patients with obstructive HCM (8). This catheterbased procedure, made attractive by its less invasive nature, was rapidl...

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Section: Alcohol Septal Ablationmentioning

confidence: 99%

Section: Technical Issuesmentioning

confidence: 99%

Section: Arrhythmogenic Potential Of Alcohol Septal Ablationmentioning

confidence: 99%

See 1 more Smart Citation

Alcohol septal ablation: in which patients and why?

Spirito¹,

Rossi²,

Maron³

2017

Ann. Cardiothorac. Surg.

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“…This increases the incidence for reentrant ventricular tachyarrhythmias and sudden death originating from the alcohol-induced myocardial necrosis and scarring in the patient with HCM, a patient who already has preexisting electrical instability and an unpredictable myocardial substrate [18]. Recent reports suggest that lethal arrhythmogenic events linked to ablation may not be uncommon [19,20]. In addition, alcohol septal ablation has also been associated with increased firing of implantable cardioverter defibrillators [13].…”

Section: Limitations Of Asamentioning

confidence: 99%

How Can we Improve Non-Surgical Septal Reduction for Hypertrophic Obstructive Cardiomyopathy?

Cleator¹,

Kasasbeh²

2016

J Cardiovasc Dis Diagn

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The goal for treatment of medical refractory Hypertrophic Obstructive Cardiomyopathy (HCM) is reduction of the hypertrophied left ventricular septum which obstructs blood flow. A surgical approach consists of an open-heart myomectomy, while the less invasive percutaneous approach involves creating a myocardial infarction by injecting 95 to 100% ethanol through a septal artery, a procedure termed alcohol septal ablation (ASA). Although less invasive than myomectomy, there are several limitations of alcohol septal ablation. The most important appears to be full thickness infarction that is often complicated by heart block and ventricular tachycardia/fibrillation. The ideal therapy for septal hypertrophy would be to find an agent that induces a less severe injury and/or atrophy of the hypertrophied septum. We review several alternative techniques for selective injury of the septum and describe the ideal characteristics of such an ideal agent. Our central hypothesis is that the anthracycline antibiotic such as doxorubicin may be the perfect agent. Anthracycline-based chemotherapies have been used in the treatment of solid and hematological tumors for many years. These agents have known cardiotoxic side effects that are related to cumulative dose which can lead to heart failure. Although the mechanism of action of doxorubicin cardiotoxicity is controversial, it is very clear that these agents cause atrophy of the myocardium, induce apoptosis and necrosis, as well as anti-angiogenic effects. We propose that selectively treating the hypertrophied septum of HCM patients with injection of the anthracycline doxorubicin will lead to superior outcomes compared to ASA.

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“…Such fears were heightened by some small observational studies, 32,33 but these were contradicted by other similar studies that indicated the technique was safe. 34,35 These conflicting results, and the lack of sufficient evidence, have created confusion that can only be resolved by large studies of patients treated by ASA with long-term outcomes and by meta-analyses comparing the results of the two techniques. In 2008 Kuhn et al published the results of 644 consecutive patients treated by ASA over a 10-year period.…”

Section: Comparison With Myectomymentioning

confidence: 99%

Alcohol septal ablation in obstructive hypertrophic cardiomyopathy: Four years of experience at a reference center

Fiarresga

Cacela

Galrinho

et al. 2014

Revista Portuguesa de Cardiologia (English Edition)

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Introduction: We describe our center's initial experience with alcohol septal ablation (ASA) for the treatment of obstructive hypertrophic cardiomyopathy. The procedure, its indications, results and clinical outcomes will be addressed, as will its current position compared to surgical myectomy. Objective: To assess the results of ASA in all patients treated in the first four years of activity at our center. Methods: We retrospectively studied all consecutive and unselected patients treated by ASA between January 2009 and February 2013. Results: In the first four years of experience 40 patients were treated in our center. In three patients (7.5%) the intervention was repeated. Procedural success was 84%. Minor complications occurred in 7.5%. Two patients received a permanent pacemaker for atrioventricular block (6% of those without previous pacemaker). The major complication rate was 5%. There were no in-hospital deaths; during clinical follow-up (22±14 months) cardiovascular mortality was 2.5% and overall mortality was 5%. Discussion and Conclusion:The results presented reflect the initial experience of our center with ASA. The success rate was high and in line with published results, but with room to improve with better patient selection. ASA was shown to be safe, with a low complication rate and no procedure-related mortality. Our experience confirms ASA as a percutaneous alternative to myectomy for the treatment of symptomatic patients with obstructive hypertrophic cardiomyopathy refractory to medical treatment. PALAVRAS-CHAVE

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Implantable Cardioverter-Defibrillator Therapy for Primary Prevention of Sudden Death After Alcohol Septal Ablation of Hypertrophic Cardiomyopathy

Abstract: The annual rate of appropriate ICD discharges after ASA is low and less than that reported previously for primary prevention of SCD in HCM. This suggests that ASA is not proarrhythmic. Traditional SCD risk factors did not predict ICD shocks in this cohort.

Cited by 78 publications

References 42 publications

Alcohol septal ablation: in which patients and why?

Alcohol septal ablation: in which patients and why?

How Can we Improve Non-Surgical Septal Reduction for Hypertrophic Obstructive Cardiomyopathy?

Alcohol septal ablation in obstructive hypertrophic cardiomyopathy: Four years of experience at a reference center

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